Urinary Incontinence - Latest Publications | An

Download Report

Transcript Urinary Incontinence - Latest Publications | An

Urinary Incontinence
Dr. Eyad Z. AL-Aqqad
Special Urologist
Involuntary loss of urine or stool in sufficent amount or
frequency to constitute a social and/or health problem.
A heterogeneous condition that ranges in severity from
dribbling small amounts of urine to continuous urinary
incontinence with concomatant fecal incontinence
How Common is Incontinence?
• Prevalence increases with age (but it is not a part of
normal aging)
• 25-30% of community dwelling older women
• 10-15% of community dwelling older men
• 50% of nursing home residents; often associated with
dementia, fecal incontinence, inability to walk and
transfer independently
Urinary Incontinence is Often
Under-Diagnoses and Under-Treated
• Only 32% of primary care physicians routinely ask
about incontinence
• 50-75% of patients never describe symptoms to
• 80% of urinary incontinence can be cured or
Why is Incontinence Important?
• Social stigmata - leads to restricted activities and
• Medical complications - skin breakdown,
increased urinary tract infections
• Institutionalization - UI is the second leading
cause of nursing home placement
Anatomy of Micturition
Detrusor muscle
External and Internal sphincter
Normal capacity 300-600cc
First urge to void 150-300cc
CNS control
– Pons - facilitates
– Cerebral cortex - inhibits
• Harmonal effects - estrogen
Peripheral Nerves in Micturition
Parasympathetic (cholinergic) - Bladder contraction
Sympathetic - Bladder Relaxation
Sympathetic - Bladder Relaxation (β adrenergic)
Sympathetic - Bladder neck and urethral contraction (α
• Somatic (Pudendal nerve) - contraction pelvic floor
Peripheral Nerves in Micturition
Taking the History
• Duration, severity, symptoms, previous treatment,
medications, GU surgery
• 3 P’s
– Position of leakage (supine, sitting, standing)
– Protection (pads per day, wetness of pads)
– Problem (quality of life)
• Bladder record or diary
Potentially Reversible Causes
- Delirium
- Infection
- Atrophic vaginitis or urethritis
- Pharmaceuticals
- Psychological disorders
- Endocrine disorders
- Restricted mobility
- Stool impaction
Medications That May Cause Incontinence
• Diuretics
• Anticholinergics - antihistamines, antipsychotics,
• Seditives/hypnotics
• Alcohol
• Narcotics
• α-adrenergic agonists/antagnists
• Calcium channel blockers
Categories of Incontinence
Urge incontinence
Stress incontinence
Overflow incontinence
Functional incontinence
Urge Incontinence
Other Names: detrusor hyperactivity, detrusor instability,
irritable bladder, spastic bladder
Most common cause of UI >75 years of age
Abrupt desire to void cannot be suppressed
Usually idiopathic
Causes: infection, tumor, stones, atrophic
vaginitis or urethritis, stroke, Parkinson’s Disease,
Stress Incontinence
• Most common type in women < 75 years old
• Occurs with increase in abdomenal pressure;
cough, sneeze, etc.
• Hypermotility of bladder neck and urethra; associated
with aging, hormonal changes, trauma of childbirth or pelvic
surgery (85% of cases)
• Intrinsic sphinctor problems; due to pelvic/incontinence
surgery, pelvic radiation, trauma, neurogenic causes (15% of cases)
Overflow Incontinence
• Over distention of bladder
• Bladder outlet obstruction; stricture, BPH, cystocele,
fecal impaction
• Non-contractile baldder (hypoactive detrusor
or atonic bladder); diabetes, MS, spinal injury,
Functional Incontinence
• Does not involve lower urinary tract
• Result of psychological, cognitive or physical
Physical Examination
Mental status
Fluid overload
Abdominal exam
Neurologic exam
Diagnostic Tests
Stress test (diagnostic for stress incontinence; specificity >90%)
Post-void residual
Blood Tests (calcium, glucose, BUN, Cr)
Urine Culture
Simple (bedside) Cystometrics
Bladder Pressure-Volume Relationship
Interpretation of Post-Void Residual
PVR < 50cc
PVR > 150cc
PVR > 200cc
PVR > 400cc
- Adequate bladder emptying
- Avoid bladder relaxing drugs
- Refer to Urology
- Overflow UI likely
Treatment Options
Reduce amount and timing of fluid intake
Avoid bladder stimulants (caffeine)
Use diuretics judiciously (not before bed)
Reduce physical barriers to toilet (use bedside
Treatment Options
• Bladder training
– Patient education
– Scheduled voiding
– Positive reinforcement
• Pelvic floor exercises (Kegel Exercises)
• Biofeedback
• Caregiver interventions
– Scheduled toileting
– Habit training
– Prompted voiding
Pharmacological Interventions
• Urge Incontinence
– Oxybutynin (Ditropan)
– Propantheline (Pro-Banthine)
– Imipramine (Tofranil)
• Stress Incontinence
– Phenylpropanolamine (Ornade)
– Pseudo-Ephedrine (Sudafed)
– Estrogen (orally, transdermally or transvaginally)
Surgical Interventions
Surgery is reported to “cure” 4 out of 5 cases, but
success rate drops to 50% after 10 years.
• Urethral Hypermotility
– Marshall-Marchetti-Kantz
– Needle neck suspension
• Intrinsic sphincter deficiency
– Sling procedure
Other Interventions
• Pessaries
• Periurethral bulking agents (periurethral injection
of collagen, fat or silicone)
• Diapers or pads
• Chronic catheterization
– Periurethral or suprapubic
– Indwelling or intermittant
Indwelling Catheter